 What is going on everybody? Welcome back to the channel. For those of you who are new around here, my name is Michael, aka Dr. Cellini and I'm in my sixth and final year of training in interventional radiology. On today's video, we are going to be talking about Alex Smith, the former quarterback for the Washington football team, formerly known as the Washington Redskins. As most of you may know, he was injured last year at the end of this season and suffered a pretty bad course in the hospital. And we're going to talk about some of the X-rays in the course of his terrible injury. Let's get into it. So for those of you who don't know, ESPN just released this kind of trailer, which I think they're going to release a longer E60 video on his entire course in the hospital and from the injury, his recovery and all that stuff. They released this seven minute trailer on YouTube in which a lot of my subscribers sent me. So we're going to watch this and kind of take breaks, talk about what he went through. So let's go. So they didn't show the actual injury, but I remember watching this game against the Houston Texans and his leg got twisted and a whole bunch of other giant NFL players fell on top of him. But we didn't know how bad it was going to be until later, obviously. I definitely sensed a pretty major fracture, at least when he first had his injury. You can actually see his foot is externally rotated pointing to the lateral side and his leg here is actually turned internally, which is not a good sign. So I bet if he kind of pulled his knee up, his leg would kind of just flop around because the bones were completely broken. As I go down, I didn't hear anything. It went fuzzy. Somebody else next to him said, I saw his legs in two different places. To know immediately your leg's broken, bending where it should bend. Also, how did they help him up or how did he even stand when he had nothing to support his right leg like that? That's crazy. I guess they like propped him up, but I don't know. You can't walk on that leg. So props to him. And I looked down at my eight year old and he is like welling up with tears and he says, mom, the cart's coming. See, this is what I always feel bad. I watch a lot of NFL football and a lot of college football and I always feel bad when these players get injured, especially the college players who are about to go to the NFL and essentially change their life. They worked for 15 plus years to get on an NFL team and then they get injured the last year of the season, which may affect their entire career going forward. And it's just terrible. One simple injury and you could be done forever playing football. Pay tribute to Alex Smith who will get the standing ovation as he is driven out of this stadium. What a moment. Immediately, I remember thinking that like season's over. That's kind of when the shotgun wore off and it got pretty painful at that point. I was just going to say I'd probably be like crying in pain right now and he's sitting there completely stoic with a straight face just waving to the crowd after his leg just got shattered. So we saw a tibia fracture that extended from his ankle all the way up to his knee. Very complex. All right. So this is his first x-ray. I guess they got it on the sidelines. I guess they have an x-ray machine outside the stadium just to go over this here. So this is pretty bad. This is the kind of stuff you would see in like a severe car accident. This is his tibia or the major bone in your leg right here and it is completely shattered here and here, which looks like a spiral comminuted fracture or when I say that it means it's broken in multiple spots. And then we also have a comminuted fracture of the fibula right here where there's a piece right here and then you have these two the fibula supposed to be like this and you can see it's broken and overlapped which is not good which is probably what was pushing out against his skin right here and I'm willing to bet there's either a fracture higher up closer to his knee and there's probably a fracture down here posteriorly as well. This is quite a severe fracture and is going to be quite an extensive surgery to say the least. You can see all this soft tissue swelling out here as well. Yeah. So comminuted fibula and spiral comminuted fracture of the tibia as well. There was bone sticking out of it. Now that it's open he's going straight to the operating room. There was actually bone protruding through the skin when this happens you presume that the bone is infection and we call it an open fracture and when you presume the fracture is infected or open you have to take them to the OR and clean out that tissue to make sure it doesn't get infected when you put it back together. So if you were to just cast an open fracture the risk for infection is extremely high which is why it's considered an orthopedic emergency and they go to the OR to repair it instead. Alex was rushed here to the Inova Fairfax Medical Campus and was immediately taken to this trauma room. There's always going to be a higher risk of infection when you have an open wound versus something that was just closed and never penetrated the skin. Say there was grass or dirt or what have you in his wound the wound didn't appear to be very large but you never know. We look at a fracture pattern and it tells us how it happened. So yeah okay so you can see actually up here closer to the knee his tibia is actually broken in two spots so up higher towards the knee or proximal as we call it and then also distally or towards the ankle and it's a spiral fracture going up and it's a comminuted fracture. A comminuted displaced spiral fracture of the tibia and also a comminuted displaced fracture of the fibula. It is open it needs to be searchably repaired in the OR which is like he just said. If there is a piece of grass or soil or sweat from somebody else or himself that is in that wound it would be infected and you to lose the leg which is why it's an emergency. You're gonna have emergency surgery and you're down in a hospital and on a stretcher like none of that's to be expected. I mean I'm still in my football gear. They said it'll be fine you're gonna go in there maybe be in the hospital for two days you know do a little bit of rehab while he's in the hospital and then be on your way. And that's pretty much how it is even if it's an open fracture pretty simple straightforward repair to an orthopedic surgeon it's a URI I would have no idea how to fix this. So then it's a pretty simple procedure repair the fracture rest in the hospital for a day or two go home with a cast on and then you follow up in the office after it heals and you follow the progress of that healing fracture. I know watching his course of his recovery that that is not what happened to him unfortunately. Book up in the room leg obviously completely wrapped up and damaged up. So these are some intraoperative films I know that just because they're not actual real x-rays they're not as high of quality as a real x-ray to be so it's more intraoperative and you can see that he has lateral and medial plate and screw fixation of his tibia which is now straight and also of his distal fibula here he has a lateral plate as well with some screws in there so they sure did straighten everything out as you can see here. So one would hope now that the fracture is straight and aligned and approximated that it would heal normally. He had two plates and multiple screws for the tibia his fibula was also broken and we plated that with a third plate. So this is a real x-ray not an intraoperative x-ray so he pretty much has this plate on the medial aspect of the tibia and also in the lateral aspect of the tibia going all the way up almost to his knee in again this plate on his fibula. He was begging me can I just go home I feel all right and so I went through his pain regimen and I said you know like you're still taking some IV pain medicines and he said I can go home I'm fine I'll be all right I can tough it out. I'm getting around on crutches and I'm fine and kind of ready to go and at that whole time I'd kind of been running an off and on little fever kind of a mild fever. So a mild fever after a surgery it's not that big of a concern because it's pretty common there is a couple things we're taught in residency and internship and all that stuff that cause these low-grade fevers postoperatively one being analexis or non-expanding lung obviously a postoperative infection is always in the back of your mind but usually doesn't happen a day or so after the surgery it'll usually present itself a little later almost five to seven plus days later. A fever of 105 or less is normal if I remember he spiked to 102, 103 or something. So that's a high fever people always call me in the hospital and say this patient is spiking a fever but then I ask him what the temperature is and they say 100 but we don't really consider that a fever in the business 105 Fahrenheit is considered a fever and 102, 103 that's the real deal and so they do blood cultures so the trauma docs went back and they looked at the wound and everything looked fine the light looked normal was beat up but it didn't look infected. So they drew blood cultures on him because he spiked a fever and the way they do that is just they just normally draw blood but they put it into an actual culture and then they grow that culture over the next 48 hours or so to see if any bug grows out of that blood. He just progressively got worse and Alex's fever is through the roof and his blood pressure is dropped. Okay that's what we worry about. You have a fever and your blood pressure starts to drop and that's when we worry about sepsis and also even worse than that septic shock. Septic shock is caused by bacteremia or bugs in your bloodstream that are circulating causing this fever causing this drop in blood pressure and when you see this happen you have to be proactive with antibiotics and hydration because you have to stay ahead of this or else it can get really bad really quickly. Not Alex anymore. It's test after test after test. I get a call then that his blood cultures are positive meaning his bacteria and his blood. If that bacteria or blood causes issues like blood pressure issues and heart rate issues becomes septic shock. Exactly so he's back to remic or he has bacteria in his blood or bugs growing in his blood and that's when you're listening to things get serious. How bad? Uncontrolled. You could die. 100%. If you don't control this if you don't start with the IV antibiotics if you don't push fluids the patient can die from septic shock very quickly. I remember the doctors coming in and unwrapping my leg in the middle of the night and clearly they were alarmed by something. We had all seen this as soon as the end of the day before and they looked like traumatized leg we've seen a million times. It was a impressive and dramatic difference. Okay so you don't have to be a doctor to know that this leg looks different than what they showed previously. It has all these boils and blisters and it's red swollen. I bet if you touched it it was probably hot. This leg is infected so what you would worry about here is infection of his skin, you worry about infection of the underlying bone and also infection of the hardware that they just repaired his broken bones with. This is a very serious situation and if not treated quickly it can lead to amputation or death. And one thing I didn't mention here is this is likely a necrotizing infection given the fact that there's these like kind of air bubbles in here and if this isn't treated it can progress and kind of march up the leg and actually involve any other parts of the body as well. It's not good this is a surgical emergency. Blisters were huge. It was something you wouldn't even I mean I couldn't fathom seeing this in like a war movie. They took him back into surgery opened all that up and I will never ever forget this as those surgeons walked out and said well we're in life-saving mode now and leg-saving mode but it's in that order. So yeah basically they left us on kind of a cliffhanger so we'll wait until we see the final documentary but yes that is a surgical emergency and you need to take him to the OR to breed all that tissue and kind of march up until you see normal tissue. You likely will have to remove some of that hardware and put kind of an antibiotic patch in there in the interim. He will not be walking on this anytime soon and at this point you are essentially trying to save his life first and the leg comes second because at this point that infection could travel up anywhere and kill him I guarantee you can just hear that ambulance and how many floors up New York City. So at this point I totally agree with him this is now a life-saving mode as in we're trying to save his life the leg will come second to his life and oftentimes they may have to amputate the leg in order to save a life. That's how serious these infections can be. So I guess we'll find out in the official documentary but I just wanted to go over that and show you some of these x-rays. I kind of know what happened because I've been following over the past year or so. So if you like this video let me know in the comments below if you want me to do another video like this where I go in depth on certain injuries and hospital courses. Send me a link to the video and I will look at it and go over it possibly. Smash that like and subscribe button, follow me on Instagram if you're done already, otherwise I'll see you all on the next video.